Cadabam's Blog

Mental rehabilitation is an important component in the management of the mentally ill. This article presents a selective review of the publications in this journal. Questions addressed in this review range from assessment of rehabilitation needs to different rehabilitation approaches. Although the number of publications providing the answers is meager, there are innovative initiatives. There is a need for mental health professionals to publish the models they follow across the country.
Mental rehabilitation is a therapeutic approach that encourages a mentally ill person to develop his or her fullest capacities through learning and environmental support.

Mental rehabilitation and psychiatric treatment are separate, yet equally important complementary components of mental healthcare. Even as psychiatric treatment (Pharmacological and psychological) aims at controlling psychiatric symptoms, psychiatric rehabilitation focuses on functioning and role outcomes. The new focus of rehabilitation is on wellness and optimum quality of life.

The rehabilitation program should start right from the first time the patient has come into contact with a mental health professional. A clinician waiting to start rehabilitation after the patient becomes asymptomatic, may not benefit the patient or the family in the long run.

This article reviews publications in the IJP from its inception to date, in the area of rehabilitation. We have tried to summarize these articles and suggest future directions. This includes editorials, commentaries, review articles, book reviews, and case reports.

Literature review

Schmidt in his article, ‘A measurement of rehabilitation of psychiatric patients,’ comments that in psychiatry, as in general medicine, a full restitution ad integrum cannot be expected even after the most efficient treatment, although, functioning can fortunately be restored after the disease. He has reported from a community-based mental health review in Sarawak, a state in the federation of Malaysia. They focused on patients in terms of rehabilitation of their previous working capacity. The rehabilitation status was measured by taking into consideration whether they were, ‘working’ ‘probably working,’ ‘Does some work,’ ‘Probably not working,’ and ‘Not working’. They assessed 584 consecutive patients visiting the clinic for follow-up and found that 82% of them were within the first three categories (‘Working’, ‘probably working’, ‘does some work’) and were functioning well, while 18% (‘Probably not working’ and ‘not working’) were not functioning, and therefore, could not claim to have been rehabilitated.

Nagaswamy carried out a very important assessment of the rehabilitation needs of schizophrenic patients. They interviewed 59 schizophrenic outpatients and their families to assess the subjective rehabilitation needs. They found that 64.4% wanted a job, 54.4% wanted some help for the family. Almost 90% of them desired rehabilitation in one form or another and most exhibited multiple needs, which emphasized the role of multifaceted, comprehensive, aftercare package programs. Even as the need for job as a priority was similar to findings in the west, this population differed by having low priority for social skills training and psycho-social structuring, in contrast to the west.

Verma and Shiv reported on the effect of rehabilitation in leprosy patients with psychiatric morbidity. They assessed 100 patients with leprosy, among whom 46 were rehabilitated and were staying in an ashram. Others were staying in a slum. They were assessed using the Goldberg General Health Questionnaire (GHQ) and Indian Psychiatric Interview Schedule (IPIS). They found statistically significant differences on psychiatric morbidity between the non-rehabilitated (85%) and rehabilitated groups (68%).

Gopinath and Rao in their invited review article, have reviewed important world literature regarding psychiatric rehabilitation. They describe the principle, components, and efficacy of various rehabilitation activities. They have discussed the scenario in India and suggested steps to be taken to improve rehabilitation efforts in India.

Kastrup have studied the psychological consequences of torture and they have described the principles of treatment. They have described a model for rehabilitation of such victims, being followed at their center at Copenhagen.

Mathai in an unique, but small case control study, tried cognitive re-training of four detoxified male alcoholics and compared it with four controls. At the end of six weeks they found a significant improvement in information processing, memory, and reduction of neuro-psychological deficits. They concluded that neuropsychological rehabilitation was effective in improving cognitive defects of abstinent alcoholics.

Agarwal in his review of the book, ‘Innovation in psychiatric rehabilitation,’ published by the Richmond Fellowship Society (India) comments, ‘Large rehabilitation facilities may be the only viable option’. He opines that there were many rehabilitation initiatives, but unfortunately most of them have not tried to evaluate their efforts scientifically as well as in economic terms.

Ponnuchamy examined the role of family support groups in mental rehabilitation. They observed that members attending support group meetings, expected to get more information about the illness, to develop skills to cope with problems at home, and to learn skills to deal with the ill person. They concluded that participation in a support group meeting positively affected key variables in the participant’s adaptation to mental illness in a relative.

Thara in a commentary has stressed the need for cost-effectiveness studies for rehabilitation. She reports the experience of Schizophrenia Research Foundation (SCARF) in rural areas, where it was found that the most suitable elements of a rehabilitation program were empowering the families and offering simple, culture-specific interventions, such as distribution of livestock and fishing nets.

Kumar have assessed the prevalence and pattern of mental disability among the rural population in Karnataka. It was a community-based, cross-sectional, house-to-house survey. They used Indian disability evaluation and assessment scale (IDEAS), developed by Rehabilitation committee of Indian psychiatric society (IPS). They studied one thousand subjects randomly. The prevalence of mental disability was found to be 2.3%. The prevalence was higher among females (3.1%) than among males (1.5%). The prevalence was the highest among the elderly and illiterates.

Suresh Kumar observed that there is a definite limitation to the domains of social functioning, cognitive functioning, and psychopathology in chronic schizophrenia patients who have had no rehabilitation. Vocational rehabilitation significantly improves these limitations, which in turn helps these patients to integrate into the society so as to function efficiently in their roles.

Each age group like children , adolescents,adult,middle age and old age has specific psychological problems , which have to be dealt with effectively to maintain our health and efficiency. The specific psychological problems, which after the age of 50 years are as follows;
(1)Depression (2) Adjustment disorders including anxiety and somatoform disorders (3) dementia
1.Depression: it is the most common mental disorder seen in this age group. It is estimated that 15 to 20% of people may suffer and at the age of 75 and above ,50% of people may suffer from this order.common symptoms of depression are as follows;
1. medically unexplained bodily symptoms like headache, backache,pain in any part of the body, fatigue , weakness , giddiness,numbness etc. all the investigations done reveal no physical abnormality . no defect or damage see in the body parts.
2. Sleep disturbances : difficulty to fall asleep,getting up early in the morning , disturbed sleep with more recall of bad dreams.
3. poor apetite , not able to enjoy the food,indigestion , constipation.
4. decreased sexual desire,inability to do and enjoy the sexual act.
5. most part of the day, the person feels bored, sad , gloomy, may move into tears very easily.
6. inability to enjoy the activities which were enjoyable earlier.
7. ideas of hopelessness,helplessness and worthlessness all the time.onemay get negative thoughts.
8. ideas of guild and sin. One may recall past mistakes and repent.
9. poor concentration and memory.difficulty to learn new things.
10. death wish,suicidal ideas and even attempts.
11. restlessness , suspicion and illusions.
It is learnt that depression disorder is due to low dopamine and serotonine(these are neurotransmitters) levels in the brain cells. genetic factors certain medical conditions like hypothyroidism,psychosocial stress factors drive the person to develop depression.
Treatment : antidepressant drugs like imipramine,fluoxetine,citalopam etc. ,councelling , emotional support from family members , healthy relaxation and recreational activities will control depression.
2. adjustment disorders : the changes in the family,loss by death or separation ,financial condition,job(retirement) and living conditions and life style may lead to adjustment disorders in the persons. The person may perceive these changes in a negative manner and as a threat to his status, well being and safety. Hemay not be able to make the required modifications and changes in his thinking , actions and reactions and its style. He may suffer from following symptoms :
i) fear and anxiety: increased heartbeats, hurried respirations , seating tremors of the hands or whole body,increased frequency of passing urine. Feelings of apprehension and anticipation of bad feeling to happen.
ii) fatigue, weakness, aches and paines, giddiness, numbness etc. in any part of the body.
iii) emotional reactions of sadness,, anger, frustratrions.
iv) sleep and appetite, sexual disturbances.
v) poor concentration,memory,inability to think , analyses and take decisions
vi) misintrepet the responses from others and environmental changes
vii) severe pre-occupation with ill health and diseases.may believe that he/she is having serious disease like heart attack , cancer
treatment : anxiolytics ( like Lorazepam, clonazepam,propranolol) antidepressant drugs,councelling,relaxation , support from family, friends or voluntary organizations.
3) dementia : as part of ageing or irreversible damage to the brain cells the person may develop the following symptoms.
i) progressive decline in memory and intellectual functions of the individual.
ii) inability to recall the names of known people , losing ones way in the known sorroundings.
iii) changes in the personality for example- a person who was very strict with money,becoming a spend thrift, a person who was very calm and serene becoming very irritable and aggressive.
iv) taking decisions without bothering about the consequences.
v) not able to take care of his needs and receiving help and guidance in day-to-day activities. At the end , becomes totally dependent on others.
vi)develops neurological deficits like fits, paralysis,tremors,in-coordinated movements of the body andlimbs.
Causes:
1. Decreased blood supply to the brain
2. Repeated bleeding inside the brain in cases of untreated or badly controlled diabetes mellitus and high blood pressure.
3. Repeated lowering of blood sugar level(below 60 mg/ 100ml) in diabetic mellitus.
4. Tumors in the brain